2Good practice
Adoption of good practice
12.Both the Department and NHS England agreed that there was a good understanding of good practice in discharging older patients from hospital.17 This includes: avoiding older people being admitted to hospital unnecessarily (for example, through setting up frailty units);18 starting assessments and discharge planning early; maintaining the momentum of treatment while in hospital, for example increasing the level of discharges before midday and at the weekend; joint/shared patient assessments between health and social care providers (‘trusted assessors’);19 and undertaking the assessment of patients long-term care needs in the most appropriate setting, whenever possible in their own home (‘discharge to assess’).20 NHS England confirmed there have been a series of publications with organisations such as the Local Government Association and the Association of Directors of Adult Social Services setting out good practice in this area.21
13.Both the Department and the Association of Directors of Adult Social Series stated that there were examples where good practice was being implemented. NHS England cited the examples of Northumbria and other vanguard areas that have been set up as part of its Five Year Forward View programme. These areas were demonstrating what can be done in implementing good practice and the impact this can have.22 The Local Government Association stated that changing the culture across organisations was vital. It cited the example of Leicester where the cultural change has been across all of the organisations with every person asking the question “Why not home, and why not today?”. The Association stated that it was important to get every person focusing on what is right for each individual patient.23
14.NHS England confirmed that not all hospitals were implementing good practice. NHS Improvement said that, in a number of areas of good practice highlighted in the NAO report, it would expect to see widespread implementation such as trusted/joint assessment and ‘discharge to assess’ schemes.24 The NAO report shows that only 49% of hospitals had ‘trusted’/joint assessment arrangements in place with their local authority and 52% had discharge to assess schemes in place where the assessment of a patient’s future care needs is done outside hospital. The Department also stated that there are some essential elements of good practice that every place should have and that over the next year there should be a systematic approach to making sure they are in place.25
15.NHS England and NHS Improvement confirmed that NHS Improvement was responsible for ensuring the spread of good practice across the NHS. NHS Improvement set out its model for the dissemination of good practice which is to encourage organisations to go and look at other organisations that are doing it well. It cited the example of the quality improvement programme it has set up at Leeds Teaching Hospitals which had resulted in a 30% reduction in delayed discharges. This is being rolled out as a pilot across the North of England with plans to take the good practice and use it across the NHS.26 Northumbria Healthcare NHS Foundation Trust said that over 50 trusts had visited to look at its systems. The Department stated that there are advantages to a bottom-up approach as you get local ownership. However, it also said that this approach needed to be balanced against the need for more pace in implementing good practice and the degree to which the centre prescribes what local areas should do.27
Sharing patient information
16.The NAO report showed that the sharing of patient information is a barrier to the smooth transition of patients into and out of hospital. This includes both the information provided to hospitals when people are admitted and also the information provided to ongoing care services (community health and adult social care) following discharge from hospital. Independent Age said that hospitals often relied on family members to provide information on a patient’s circumstances outside hospital. It said that families often have to repeat background information, such as current medication, across different people and organisations they encounter. Independent Age had concerns about how information was provided for those patients who did not have people to represent them.28
17.Northumbria Healthcare NHS Foundation Trust said that in an acute hospital setting they are often dealing with patients they have never seen before. The Trust recognised the importance of its hospital staff being able to access patient information and, in particular, its ability to interrogate GP patient records. It described the IT system it had recently put in place which allows hospital staff, community nurses and social workers to access appropriate parts of the GP record. This information helped them to: avoid stopping care packages; ensure that adequate support is in place when patients leave hospital; and highlight to community nurses areas that may require further monitoring and assessment.29
18.Northumbria Healthcare NHS Foundation Trust also highlighted the important role played by community matrons in sharing patient information and ensuring continuity of care for patients. The Association of Directors of Adult Social Services said that there was local variation in the extent to which community matrons are used and patient information is shared.30 The NAO report showed that the numbers of nurses working in community services had fallen by 13% between 2009 and 2015.31
18 Frailty units are dedicated teams of specialist doctors, nurses, therapists or social workers operating in A&E and short stay units to carry out early assessment of older patients’ needs.
19 Under trusted assessor arrangements, health and social care professionals complete a single assessment of patients’ needs, which can be shared, reducing duplication.
20 Under ‘discharge to assess’ schemes, planning, assessment and arranging ongoing care takes place in the patient’s home rather than hospital, as soon as their acute treatment is complete.
25 Q 151; C&AG’s Report, figure 10
28 Q 32, C&AG’s Report, para 3.20
31 C&AG’s Report, para 3.7
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19 July 2016